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2,— d ©/lSG— PRin1 <br /> *k,, y • Application for Onsite For city Use Only; (� If/v <br /> , -______,_ <br /> Wastewater Treatment System tyof L Ef ) <br /> L <br /> Date Received ii <br /> MAR ION COUNTY PUBLIC WORKS Received by <br /> MAY 172023 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155SiivertonRd.NE Fee A�ARIOt� COUNTY <br /> Salem Q �� ° BUILDING INSP_ ECTI•N <br /> (503)588-514'� f'a$(503)�5$S-?998 RBt't� <br /> . " wnw.co.marion.or.us/PW/auildinulnsnection Activity# <br /> ? A.property Owner Information / . <br /> -: IA 7 ss, t�,,ait(.K,.at- MO to(C AAA(.1ns-..+ t t,,14 O <br /> � <br /> \. V:"Name Mai•ling.Address _ City!,S and Zip (Area Cot <br /> � � B.Legal Property Description <br /> Tax Lot Acreage or Lot-Size <br /> :.: Legal Descnptiori��. �; ' <br /> Subdivision Name Lot Block <br /> 2.() t Sego.4iG.,4--t. ik s <br /> �.�° �to �`��'" <br /> Property City Zip Co <br /> Directions to Property: <br /> C.Existing Facility 1 Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply. <br /> } ingle'FamityResidence l"Single� yResidence, ❑Pubtie. <br /> Name <br /> Number of Bedrooms k Number of Bedrooms 0 Private= <br /> x 0 OtherWell,Spring,❑ Other - g S <br /> D Type of Application <br /> ' <br /> -❑ Site Evaluation CIRenewalPermit ❑Authorization Notice for <br /> Construction Permit 0 Permit,Reinstatement 0 Replacing a Dwelling <br /> TZ ep it Permit 0 Permit Transfer ❑ T he Addition of One or More Bedr <br /> Major 0 Minor 0 Existing System Evaluation ' 0 Personal Hardship <br /> CIA.lterationPerrmit tt Record Review 0 Temporary Housing <br /> ❑ Major.,❑Minor 0 Other. .❑ Connecting to anExisting System <br /> :(over 5-yrs old) <br /> y <br /> Other Specrfy <br /> If the required fee and attachments are not included with this application,it will be returned to you as incomplete. ; <br /> Post the orange card atthe entrance to the property, Flag the test holes. <br /> Bymy;signaiure,1 certi6r that.the information I have furnished incorrect,and hereby grant Marion County,authorized <br /> Department of Environmental Quality,permission.to enter onto the above described property for the sole purpose of th <br /> Fci . <br /> Applicant's Name—Pt):ase Print Legibly pp icant's Phone Number DEG Lie.# (if applicable). <br /> 3 <br /> A Ito E i'Ylailin�Address itB ! - � <br /> pP <br /> 2 <br /> � 'r8 b � <br /> tine <br /> Date:. GCB# (if applicable) <br />